Pediatric resident reflection from Arusha, Tanzania: Michelle Greene

If you have been in medicine for any length of time, you can probably look back to a handful of moments that impacted you: the anguish of a patient death, having someone look to YOU as their doctor (instead of your attending or your upper level resident), the thrill of encountering a diagnosis you’ve only read about, the joy of curing an illness, the frustration with the healthcare system, the unnerving chaos of an overworked clinic, or a time you felt completely ineffective when treating a patient. Remember all of that? Take that, and cram it…all of it…into a 24 hour period. And then do it every day, back-to-back. Throw in the fact that you cannot speak the language around you, and you don’t know the cultural context of anyone’s words or actions, and you have a rough approximation of what it might be like to do a medical mission trip. That was certainly my experience in Tanzania, where I was fortunate enough to visit for a rotation at the end of my pediatric residency. Of course it’s hard to summarize this succinctly to the numerous people who asked “how was your month?” when I knew they were probably looking for a bright, quick comment— “it was great!”—and maybe a few picturesque snapshots on my phone.

I don’t think anyone can understand the wild variation of emotion that happens on a day-to-day basis in global health unless they have lived it, even for a short time. This month was the first time I felt like I made a lifesaving diagnosis—“lifesaving” being a poor descriptor because corrective surgery will be likely unobtainable. But I was able to see the drastic improvement after symptomatic treatment, and I saw that infant smile for the first time since admission, which was such a gift. However this rotation, again fitting the “emotional rollercoaster” theme, was also a time of very new emotions about patient death. I personally managed one child who passed away hours after admission, and I was the physician who ordered for resuscitations to be stopped on another infant. This is an entirely different experience than the death of a patient managed by your attending; no one else is there to look at the family and say “I’m sorry” (or whatever other inadequate phrase you might say), or to diffuse that heaviness that hangs in the air after a baby dies. For me, it was an immense reminder of what it means to fully be a physician, and how closely life and death are intertwined.

I look back at my required list of objectives that I dutifully created before I left, and yes, I completed them, but reading them made me realize how different I was when I wrote them, and how much I didn’t understand. For example when I wrote, “increase knowledge of public health, infectious disease, malnutrition” for one objective—how limited and inadequate that was! You will learn about those conditions if you travel, but writing that objective and reading articles won’t prepare you for the reality of looking at a baby who is dying of HIV because the mother refuses medication, because she believes the virus is caused by witchcraft, only to be cured by devout religious faith. It won’t prepare you to see another baby pass away slowly from lack of oxygen simply because you don’t have a ventilator, or another who decompensates simply because a physician wasn’t called sooner. There were families who refused hospital treatment because their children’s infectious illnesses were caused by an evil “look” from someone, and only their traditional healers can heal that—no matter how much antibiotic you offer! In cases like these, I wasn’t able to provide any real medical help to patients for one reason or another. This forced me to reframe my interactions with patients and families; since I didn’t have any medicine, all I could offer was humanity. Over those weeks, my barrage of mental questions shifted away from things like, “what am I getting out of this experience?” or “how can I be more comfortable in this situation”, and “how can I change other people’s opinions with my awesome Western medical education?” (Maybe I didn’t think that verbatim, but it was definitely true.) By the end of the month, the thoughts were somewhat more centered around other people… “how can I be kind to this person or connect with them, even if I cannot offer them a cure?” “How can I show this person I care without even talking to them?”

I don’t mean to say that all the experiences were negative—that couldn’t be farther from the truth!  For every death or loss, there are so many more shining memories of mothers smiling in gratitude, faces of children who shyly grinned and hid behind their mothers’ skirts, with small voices that squeaked “mzungu!” (white person). There were older children who yelled at me on my way to work with wide open smiles, heads back, saying in run-on English, “howareyouhowareyouhowareyoui’mfine!” There were hugs from patients on the day they went home after weeks of slow treatment with sometimes halting progress—ones we thought on admission would surely die. There was seeing a girl walk after months of malnourishment had left her weak, edematous, and listless in bed, and all we did was FEED her. And there was my favorite story of a Maasai man I had just met who casually proposed to me during a conversation (I turned him down.)

I cannot begin to describe the warmth and the resilience of the patients and families I met, both within and outside the hospital. People with debilitating and deforming diseases smiled constantly, playing and singing. They were so fiercely and contagiously happy, in a way that our culture tells us is incompatible with physical illness and poverty. People in Tanzania dealt with various challenges with grace, such as random power outages, or no power at all, drug shortages, patient deaths, bureaucratic frustrations, inhumane work schedules (another topic altogether—medical trainees there know no such thing as duty hour restrictions). Families sometimes lived for days to weeks with an admitted child in a cramped hospital room containing 6 patient beds and easily over a dozen people, including family members. All this was endured with a grit and peaceful tenacity like nothing I have ever seen.

After looking back on all these moments, even over just a few weeks, I recognize more that I have fallen victim to the permeating concept that westerners have a responsibility to “save” people who have less resources. I often felt guilty for not using my abilities in a remote corner of the world, although intellectually I knew I could not single-handedly shift a healthcare system. While I still believe that each person has an obligation to serve and help others, I don’t think it looks like what I envisioned before this trip. The people there that made the most impact were ones who did seemingly small things, or did big things through many, many days of tiny, mundane acts. Some of those things were as simple as making residents and interns feel appreciated and respected, explaining situations thoroughly to families, advocating for specific resources for individual patients, giving anticipatory guidance and reassurance, and starting discussions among healthcare providers about taboo topics such as abuse and violence. No one has to travel 8000 miles to do those things.

I don’t know if I will ever return to Tanzania, although I hope that I do, but wherever I end up practicing medicine, I know I will see patients differently than I did before this trip. I see poverty differently, and death. My view on kindness and humanity is enriched beyond what I could imagine. If you want to know exactly what kind of difference I’m talking about…grab your smartphone and book a ticket. And then buckle up and get ready for that emotional rollercoaster!